Telehealth Informed Consent and Treatment Agreement

Telehealth Informed Consent and Treatment Agreement

Altera Health P.C. d/b/a Top Tier Psychiatry

Please read this document carefully. It describes how your care will be delivered, your rights, your financial responsibilities, and your consent to treatment. By signing below, you agree to the terms described in this document.

Section 1: Consent to Telehealth Services

What is telehealth? Telehealth means receiving healthcare through secure video and audio technology instead of going to a doctor's office in person. You will see and speak with your provider on a screen, just like a video call.

How it works:

• Your appointments will take place over secure video and audio connections
• You need a device with a camera, microphone, and internet access
• You must be in a private, quiet location during your appointment
• You must be physically located in a state where your provider is licensed

Benefits of telehealth:

• No travel time or waiting rooms
• Access to care from the comfort and privacy of your home
• Reduced scheduling conflicts
• All visits are by appointment only, protecting your privacy

Risks and limitations:

• Your provider cannot physically examine you
• Technology may fail or disconnect during your session
• There are privacy risks any time information is sent electronically, even with security measures in place
• Not all conditions can be fully evaluated or treated through telehealth
• In rare cases, your provider may determine that an in-person visit is needed and will help you arrange one

If your connection is lost: Our staff will attempt to reconnect with you. If we are unable to reconnect, we will contact you to reschedule.

Your right to refuse: You may refuse telehealth services at any time. Refusing telehealth will not affect your right to receive care in the future, though your service options may be limited.

Emergencies: Telehealth is NOT for emergencies. If you are experiencing a medical or psychiatric emergency, hang up and call 911 immediately or go to your nearest emergency room. You may also call the 988 Suicide and Crisis Lifeline by dialing 988.

Emergency contact information: You will be asked to provide a current physical address and an emergency contact person at each visit so that emergency services can reach you if needed.

Section 2: Consent to Psychiatric Treatment

Services we provide:

• Psychiatric evaluations and diagnosis
• Medication management, including controlled substances (Schedules II through V) when your provider determines it is clinically appropriate
• Pharmacogenomic testing (such as GeneSight) -- this test is performed by a third-party laboratory and helps your provider choose medications that may work better for you
• Emotional support animal (ESA) evaluations
• We do not currently provide psychotherapy, counseling, or talk therapy

Risks and benefits of treatment:

• Psychiatric medications may help manage your symptoms and improve your daily functioning
• All medications carry risks of side effects, which your provider will discuss with you
• Medications may not work as expected, and it may take time to find the right treatment
• There is no guarantee of any particular outcome

What we cannot promise:

• We do not promise that you will receive a diagnosis. Your visit is an assessment. Your provider may or may not give you a diagnosis based on what they find.
• We do not promise that medication will be prescribed. Whether you receive medication depends on your assessment, any diagnoses, and your provider's medical judgment.
• If medication is prescribed, we do not promise that your pharmacy will have it in stock or that your insurance will cover it. We cannot promise what the medication will cost. Top Tier Psychiatry does not control pharmacy inventory, insurance formularies, or drug pricing.
• If medication is prescribed, it is your responsibility to follow up with your pharmacy to make sure it is processed and ready. Top Tier Psychiatry is not responsible for contacting the pharmacy on your behalf. If you have checked with your pharmacy and there is still a problem, please reach out to us and we will help.

About controlled substances:

• Controlled substances carry additional risks including dependence, tolerance, and withdrawal
• Refills require active appointments -- your provider will not refill controlled substances without a clinical follow-up
• Early refills are generally not provided
• Your provider may require drug screening at any time as a condition of prescribing controlled substances
• Your provider may discontinue prescribing any medication if their clinical judgment requires it

Your provider:

• All providers are licensed in the state where you are physically located during your appointment
• Providers may include psychiatrists (MD/DO), psychiatric nurse practitioners (PMHNP), physician assistants, and other qualified mental health professionals
• Provider credentials are verified through state licensing boards

Your rights:

• You have the right to ask questions about any medication, diagnosis, or treatment recommendation
• You have the right to refuse any treatment
• You have the right to request a different provider

Section 3: Consent for Minors (if applicable)

If the patient is under 18 years of age, a parent or legal guardian must review and sign this document on the patient's behalf.

• Parent/guardian must provide consent for treatment
• Parent/guardian must be available for the initial evaluation and as requested by the provider
• Parent/guardian has access to the minor's medical records except where state law provides confidentiality protections to the minor
• The provider may exercise clinical judgment regarding what clinical information to share with the parent/guardian

Section 4: Use of Technology in Your Care

Top Tier Psychiatry may use technology tools, including artificial intelligence, to assist with clinical documentation and other administrative functions related to your care.

• Only company-approved technology tools may be used in connection with patient care
• Clinical decisions, including diagnosis, treatment planning, and prescribing, are always made by your licensed provider -- technology tools assist with documentation only
• If you have any questions about the use of technology in your care, please contact us at info@toptierpsych.com or (725) 272-2411

Section 5: Financial Responsibility

Insurance patients:

• It is your responsibility to verify that your insurance plan is accepted before your appointment
• Copayments, coinsurance, and deductibles are due at the time of service
• If your insurance denies or reduces a claim, you are responsible for the remaining balance
• Benefit verification is not a guarantee of payment by your insurance company

Self-pay patients:

• Payment in full is due at the time of service
• Self-pay rates will be provided at the time of scheduling
• You have the right to receive a Good Faith Estimate of expected charges under the No Surprises Act

Cancellation and no-show policy:

• Cancellation window: 24 hours before your scheduled appointment
• If you cancel inside that window, or miss your appointment, any amount you already paid for that visit is forfeited
• If you are using insurance, a fee is charged IN ADDITION to the forfeited amount: $50 for a late cancellation, $100 for a no-show
• If you are paying for your own care, the amount you paid is forfeited and nothing further is charged
• These fees are not billable to insurance and are your sole responsibility
• Repeated no-shows or late cancellations may result in discharge from the practice

Payment processing:

• Payments are processed through Stripe, a secure, PCI-DSS compliant payment processor
• We do not store your full credit or debit card number
• By providing your payment information, you authorize Top Tier Psychiatry to charge applicable fees to your designated payment method
• A credit card on file may be required
• By using our services, you authorize us to confirm to a payment processor, card network, or financial institution the fact that you received services from us -- and only that fact -- solely in the event you initiate a payment dispute or chargeback that requires adjudication by that processor. No clinical details are disclosed under this authorization.

Collections:

• Outstanding balances may be referred to a third-party collection agency
• You will be responsible for any collection costs to the extent permitted by law

Minor patients: For patients under eighteen (18) years of age, the parent or legal guardian is financially responsible for all charges, including copayments, deductibles, coinsurance, no-show fees, and late cancellation fees. Billing and financial notifications are sent to the parent or legal guardian. Appointment reminders and care-related notifications are sent to both the parent or legal guardian and the minor patient when separate contact information is on file.

Section 6: Communication Preferences

Your communication preferences will be collected during the intake process.

Section 7: Privacy and Records

• Your health information is protected by HIPAA and applicable state law
• Our Notice of Privacy Practices describes how your information may be used and disclosed
• You have the right to access your medical records by contacting info@toptierpsych.com
• Medical records are retained per applicable state and federal law

Section 8: Practice Policies

Appointments:

• All services are by appointment only -- no walk-in services are available
• Please be on time -- late arrivals may result in a shortened session or rescheduling

Between appointments:

• For emergencies: call 911 or go to your nearest emergency room
• For crisis support: call 988
• Please allow 2 business days for a response to non-urgent messages
• Medication refill requests require 5 business days advance notice

Discharge from the practice: Top Tier Psychiatry may discharge a patient for: repeated no-shows or late cancellations; non-compliance creating safety concerns; threatening or abusive behavior; failure to pay outstanding balances; providing false information; or violations of controlled substance policies. We will provide reasonable notice and assist with transfer of care.